Taking outside in, turning inside out: Exploring social dimensions and psychotherapeutic process in the play therapy of a young girl in foster care.

This paper, a collaborative effort, describes the work of A Home Within (AHW), a volunteer community-based organization providing pro-bono long term psychotherapy to current and former foster youth. We provide a brief description of the treatment model, present a report of treatment conducted by an AHW volunteer, and discuss further reflections on the societal context of our psychoanalytically-informed work. In-depth psychotherapeutic process from the treatment of a young girl in a pre-adoptive foster placement elucidates the psychotherapeutic possibilities when a psychoanalytic treatment model is accessible to current and former foster youth, usually deprived of this form of treatment due to overburdened, underfunded community mental health systems in the U.S. Open-ended psychotherapy afforded this traumatized child an unusual opportunity to work through past relational traumas in order to form new and more secure attachment relationships. We reflect further on the case from the vantage points of both the psychotherapeutic process and the greater societal context of this community-based program.

Improving outcomes for babies and toddlers in child welfare: A model for infant mental health intervention and collaboration.

Children under three comprise a sizable and growing proportion of foster care placements. Very young children who enter the child welfare system experience disruptions of critical attachments that are essential to this formative stage of brain development, as well as other traumatic events, leaving them at great risk for lifelong impairments. To reverse these concerning outcomes, babies who have been removed from their homes require intensive, relationship-based interventions that promote secure attachment to a primary caregiver and holistic attention the child's developmental needs. Child welfare decision-makers must be informed of infant brain development and knowledgeable about the particular needs and circumstances of each child. This article describes a model with these features that has been developed and tested in the Bronx, New York, one of the nation's poorest urban counties with high rates of foster care. The Project utilizes evidence-based Child-Parent Psychotherapy (CPP) as its core intervention, and emphasizes collaboration and information sharing- driven by the CPP clinician- with judges, child welfare workers, attorneys and other social service and mental health providers, thereby encouraging developmentally and relationally informed case planning and permanency decisions. The model is evaluated using pre and post treatment psychosocial measures and program outcome data. Results indicate improvement in parenting interactions, positive child welfare outcomes (including increased rates of reunification, fewer returns to foster care), and improved safety and wellbeing. Results highlight the need for child welfare practices to be more closely aligned with the current science of infant brain development, and to incorporate a specialized approach to address the unique needs of infants.

Addressing the mental health needs of looked after children in foster care: the experiences of foster carers.

WHAT IS KNOWN ON THE SUBJECT?: In the UK and internationally, the number of looked after children is increasing year on year. Mental health problems among looked after children are significantly higher than in the general population, and the uptake of mental health services for these children is low. There is a poor prognosis for children with untreated mental health problems; this is further compounded if the child is within the care system. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This study adds to our understanding of foster carers' experiences of the mental health needs of looked after children and demonstrates some of the challenges associated with accessing appropriate and timely mental health services. New knowledge derived from this research is that the barriers to accessing Child and Adolescent Mental Health Services (CAMHS) are not at the time of initial referral as previously reported, but later, once within the mental health system with long waiting times experienced particularly for specialist services. This study provides new insights into the experience of being a foster carer and the levels of support and resources needed that directly relate to the viability of the placement. The majority of the foster carers interviewed were from a Black and Minority Ethnic (BME) background, previously under-represented in this research area. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A number of areas in current CAMHS provision need addressing with a focus on accessibility, consultation and support for foster carers. Waiting times need to be addressed, and improved communication with other agencies is also highlighted. CAMHS nurses are well placed to develop and deliver a comprehensive care package to foster carers, offering more tailored support to them whilst enabling the children and young people in their care to access and engage more effectively with mental health services. ABSTRACT: Introduction Despite well-documented vulnerabilities to mental health problems among the increasing population of looked after children, there continues to be poor uptake and utilization of Child and Adolescent Mental Health Services (CAMHS). Aim To elicit views of foster carers regarding the mental health needs of children and adolescents in their care and their experiences of accessing mental health services. Methods A grounded theory approach and semistructured interviews with ten foster carers. Results The experience of being a foster carer was the core category, with three major themes: (1) foster carers' psychological understanding of challenging behaviour; (2) barriers to accessing CAMHS; (3) the importance of support. Discussion A key finding of this research is that barriers to accessing CAMHS were not experienced at the point of referral, but once within the mental health system. The foster carers demonstrated a proactive approach to accessing services but expressed a need for more support structures related directly to the viability of the placement. Implications for practice Mental health nurses have a pivotal role in providing a more responsive and needs-led service for this population; professional support to foster carers to include facilitating peer support; and clinical interventions for the looked after children.

Neuro-Physiological Psychotherapy (NPP): The development and application of an integrative, wrap-around service and treatment programme for maltreated children placed in adoptive and foster care placements.

This article describes the development and application of a wrap-around, multidisciplinary, brain-based, developmental and attachment-focussed intervention for children who have experienced significant trauma in the context of their early life. It outlines the presentation of the children and families who are referred to the service and the model of treatment that they receive. In doing so, it identifies the core components underpinning Neuro-Physiological Psychotherapy (NPP) and links the application of the integrative model to research and practice in the field of neuroscience and attachment and to the use of therapeutic approaches that are beneficial to maltreated children and their adoptive parents. It highlights the need for a neuro-sequential approach that impacts all aspects of the child's life in the effort to redress the impact of developmental trauma with the aim of improving their overall functioning and their ability to develop healthy relationships into the future.

Challenges of Assessing Maltreated Children Coming into Foster Care.

Children who have experienced early adversity have been known to be at risk of developing cognitive, attachment, and mental health problems; therefore, it is crucial that children entering foster care can be properly assessed as early as possible. There are known difficulties in assessing children in foster care, for example, in finding a reliable informant. An ongoing randomised controlled trial in Glasgow, Scotland, recruiting infants entering foster care, provides a unique opportunity to explore some of the issues which need to be considered when assessing these children. The assessment data of 70 infants entering care is described while exploring the reliability of foster carers as informants and the importance of infant engagement with tasks. This group of infants was shown to be having more problems than children from the general population. While correlations were found between a carer's level of concern about a child and the severity of a child's problem, there were still a number of children displaying worrying problem scores whom foster carers did not report concern. The child's engagement in the cognitive task showed associations with the child's attainment on the task. Findings emphasise the importance of a holistic assessment for these children and all should be considered as potential cases with Maltreatment-Associated Psychiatric Problems (MAPP).

Impact of protective factors on resilience of grandparent carers fostering orphans and non-orphans in Zimbabwe.

OBJECTIVE: This study sought to explore the impact of protective factors, health, and well-being on resilience of grandparents fostering orphans. METHOD: Data were collected from grandparents (N = 327; M age = 62.4; SD = 11.2) in Zimbabwe using a survey instrument comprising the Resilience Scale and World Health Organization Quality of Life Questionnaire (WHOQOL-BREF). Data were analyzed using hierarchical regression, predicting resilience from demographics, personal and social assets, health, and well-being. RESULTS: Protective factors associated with resilience were personal assets (high self-esteem, problem-solving skills, and mastery) and social assets (social networks and spirituality). Grandparents with higher coping skills, younger age, and high socioeconomic status (SES) had superior personal competences for resilience than peers with lower self-rated personal attributes. Grandparents with good physical and mental health had higher resilience profiles. DISCUSSION: Positive emotions and good health experienced by resilient grandparent carers function as protective factors to reduce the magnitude of adversity to individuals and assist them to cope well with caregiving.

[Trauma, developmental stages, and motivational abilities in indentured Swiss child laborers in old age]. / Traumata, Entwicklungsperioden und motivationale Fähigkeiten bei Schweizer Verdingkindern im Alter.

OBJECTIVES: The study examined the relationship between potential traumatic events in childhood and motivational abilities in old adulthood according to developmental stage. METHODS: The motivational abilities of self-efficacy, conscientiousness and impulsivity (self control) were investigated in a sample of 114 formerly indentured Swiss child laborers. Adversities were assessed by the Childhood Trauma Questionnaire (CTQ). The sample was split into four age groups according to the beginning of the potential trauma: infancy (0-2), preschool (3-5), early childhood (6-9), and early adolescence (≥ 10). RESULTS: The strongest relationship was found between self-efficacy and CTQ in the group "early adolescence," followed by the relationship between conscientiousness and CTQ in the same group. Impulsivity and CTQ were most strongly associated in the "preschool" group. CONCLUSION: Childhood adversities seem to have a negative impact on self-efficacy and conscientiousness after the age of ten. In contrast, self-control seems to be affected by the deleterious effect of trauma or adversity already at an earlier age.

Forensic psychiatry in France: the Outreau case and false allegations of child sexual abuse.

During the Outreau case in France, 13 individuals were falsely accused of child sexual abuse and incarcerated. The author of this article testified as a psychiatric expert when the convictions were appealed. He explains how purposeful false statements by adults, inept expert witnesses, and the judicial assumption that children do not lie converged to create a tragic legal outcome. This article explains how psychiatric experts should conduct evaluations in cases of alleged child sexual abuse.

Cigarette, marijuana, and alcohol use and prior drug treatment among newly homeless young adults in New York City: Relationship to a history of foster care.

BACKGROUND: This study examined whether a history of foster care was associated with the risk for substance use among newly homeless young adults, controlling for demographics and other risk factors. METHODS: Multiple logistic regression analyses, adjusted for controls, among consecutive admissions of 424 newly homeless young adults (18-21 years), determined the association between foster care and substance use. RESULTS: A history of foster care was reported by 35% of the sample. Alcohol, marijuana, and cigarettes were the most frequently used substances. After adjusting for demographics, childhood emotional, physical, and sexual abuse, prior arrest, unemployment, lack of high school diploma, and family drug use, homeless young adults with histories of foster care were: three times as likely to smoke cigarettes (AOR=3.09); more than three times as likely to use marijuana (AOR=3.30); and almost nine times as likely to have been in drug treatment (AOR=8.81) than those without such histories. CONCLUSIONS: It is important to screen homeless young adults who exited foster care for substance use, particularly cigarettes and marijuana. Risk reduction interventions should be targeted and tailored to their substance prevention needs.

Perceptions of coparenting in foster care.

Although literature supports the association between harmonious coparenting practices and lowered child problems, little is known about coparenting influences among family constellations in the foster care system. Via a compilation of a new coparenting practices measure, we examined similarities and differences on foster parent-derived perceptions of support/flexibility, shared communication, conflict/triangulation, and total coparenting between foster and biological parents and their independent contribution to child internalizing and externalizing problems. Self-reports were gathered from foster parents (N=80) in 2 groups: kin and nonkin. As compared with nonkin, kin foster parents reported higher perceived support/flexibility, shared communication, and total coparenting. A tendency for higher conflict/triangulation among kin foster parents was also found. After considering foster parent group, psychological distress, and harsh discipline, hierarchical regression analyses revealed that perceived total coparenting and conflict/triangulation contributed to child internalizing and externalizing problems. Results support the linkage between perceptions of coparenting and child problems among caregivers (foster and biological alike) in kin and nonkin arrangements and highlight training in coparenting in general, and conflict management in particular, as an important intervention focus to reduce the high level of child problems in this vulnerable population.

The role of faith in adoption: achieving positive adoption outcomes for African American children.

African American children are overrepresented in foster care by more than twice their proportion in the population (U.S. Government Accountability Office [USGAO], 2007). Building upon research relating faith (religiosity) to positive health and mental health, this study utilized cognitive and religious coping theories to examine the influence of faith on choosing to adopt, achieving positive adoption outcomes, and reducing disproportionality. From Louisiana and Texas, 113 families who adopted 226 children, 48% African American, participated in a survey measuring children's behavior and parent distress (PSI-SF Difficult Child and Parent Distress Subscales) and religiosity (Hoge Intrinsic Religiosity Index). Of the respondents, 93% of the respondents belonged to a religious congregation, 86% attended church weekly. Controlling for child's behavior, religiosity predicted lower stress in adoptive parenting; church attendance was related to improvement in parental health since adopting. Faith was rated most frequently as essential in parents' decisions to adopt. The study concludes that faith may be an asset in increasing adoptions and improving adoption outcomes resulting in increased numbers of African American children adopted.

Profile of young people attending alcohol and other drug treatment services in Aotearoa, New Zealand: clinical file search.

OBJECTIVE: The aim of the present study was to provide a profile of young people attending alcohol and other drug (AOD) treatment services in Aotearoa, New Zealand. METHOD: Data were gathered from a clinical file search of 184 randomly selected young people aged 13-19 years who had attended one of eight youth AOD treatment services in New Zealand during 2003 or 2004. These services represented eight of the 11 youth-specific AOD services available to youth in New Zealand. RESULTS: Young people who attend youth-specific AOD services in New Zealand present with a range of complex needs including substance use and mental health issues, criminality, family conflict and disengagement from school. A total of 62.0% were male, 56.4% had criminal convictions, 40.6% had spent some time in Child, Youth and Family Services care and 53.8% were reported to have a coexisting substance use and mental health disorder. Low rates of reporting of substance use and mental health diagnoses in treatment files suggest that substance use and mental health disorders among this population are likely to be higher than those reported. CONCLUSIONS: This paper provides a unique profile of young people attending youth-specific AOD treatments in New Zealand. Such information is useful in informing treatment planning and funding and ensuring that service development occurs to specifically meet the complex needs of this patient group.

Therapeutic work with a physically abused preschooler.

This paper explores the impact of early abuse by a parental figure (foster mother) on a child's subsequent development. The child's adoption into a nurturing home at age 3-1/2 allowed for early intervention, and a brief follow-up period of treatment at age ten provides further insight into the impact of early trauma across developmental periods. The paper highlights unique challenges that may arise in treatment with child victims of interpersonal violence. During treatment, the child struggled with profound difficulty tolerating his natural aggressive impulses and distinguishing inner fantasies from external stressors. Significant modifications in treatment format, including encouraging the adoptive mother to be an active participant and using settings outside the consultation room when the child could not tolerate affects associated with the familiar playroom, were helpful in moderating the child's anxiety.

Role of traditional healers in psychosocial support in caring for the orphans: a case of Dar-es Salaam City, Tanzania.

Orphans are an increasing problem in developing countries particularly in Africa; due to the HIV/AIDS pandemic; and needs collective effort in intervention processes by including all stakeholders right from the grass roots level. This paper attempts to present the role of traditional healers in psychosocial support for orphan children in Dar-es-Salaam City with special focus on those whose parents have died because of HIV/AIDS. Six traditional healers who were involved in taking care of orphans were visited at their "vilinge" (traditional clinics). In total they had 72 orphans, 31 being boys and 41 being girls with age range from 3 years to 19. It was learned that traditional healers, besides providing remedies for illnesses/diseases of orphans, they also provided other basic needs. Further, they even provided psychosocial support allowing children to cope with orphan hood life with ease. Traditional healers are living within communities at the grass roots level; and appear unnoticed hidden forces, which are involved in taking care of orphans. This role of traditional healers in taking care of orphans needs to be recognised and even scaling it up by empowering them both in financial terms and training in basic skills of psychosocial techniques in how to handle orphans, in order to reduce discrimination and stigmatisation in the communities where they live.

An exploration of the health and social wellbeing needs of looked after young people--a multi-method approach.

This study, which was undertaken in Northern Ireland, aimed to identify how the promotion of the health and social wellbeing of looked after young people could be enhanced using a four-stage triangulated research design employing qualitative and quantitative elements. Stage 1 sought to identify relevant health issues from a representative sample of case files and found low uptake of statutory medical assessments, relatively few physical health problems and higher levels of mental health and behavioural problems including self-esteem and self-image issues. Stage 2 sought to ascertain, through two focus groups, the views of those caring for looked after young people foster carers and residential social workers. Findings showed that both groups perceive themselves in a health promoting role with the main issues encountered being the need for support in issues such as sex education and access to sources of help and aids to health promotion. Stage 3 sought to listen to the needs and concerns of the young people and their parents through a series of semi-structured interviews. These revealed the need of parents for involvement with their child's care and identification of the social worker as holding primary responsibility for health. Young people had positive views of health, identified stressors and perceived that too much help was given in relation to health issues; social workers were preferred for discussion of sensitive subjects. It was concluded that the multiple needs of young people give excellent opportunities for the development of interdisciplinary working in the context of multi-sectoral involvement to support effective health promotion interventions.

Multisensory intervention improves physical growth and illness rates in Korean orphaned newborn infants.

The purpose of this study was to evaluate the effectiveness of a multisensory intervention on the physical growth and health of Korean orphaned infants. Fifty-eight full-term infants were randomly assigned to a control (n = 28) or an experimental (n = 30) group within 14 days postbirth. In addition to receiving the routine orphanage care, infants in the experimental group received 15 min of auditory (female voice), tactile (massage), and visual (eye-to-eye contact) stimulation twice a day, 5 days a week, for 4 weeks. Compared to the control group, the experimental group had gained significantly more weight and had larger increases in length and head circumference after the 4-week intervention period and at 6 months of age. In addition, the experimental group had significantly fewer illnesses and clinic visits. These data demonstrate that multisensory intervention in conjunction with human/social contact may be effective in facilitating growth for newborn infants placed in orphanages.

Substance dependency among homeless American Indians.

Extensive qualitative research in the San Francisco Bay Area in California and in Tucson, Arizona, indicates strong associations between substance abuse and homelessness among American Indians. This article takes a comparative approach to describe and analyze precipitating factors and survival patterns of those who are both homeless and who suffer from substance dependency. Possible precipitating factors presented through case studies consider the complex interaction of childhood fostering or adoption into non-Native families, different types of involuntary institutionalization during youth, and the personal impact of accident, trauma and loss. Coping strategies and keys to survival are examined, including the role of the extended family and close friendships, American Indian and mainstream organizations that offer formal and informal services, the existence of anchor or key households, the helping relationships and sobriety groups among homeless individuals, spirituality, and cultural resiliency.

The phallic child: its emergence and meaning in a clinical setting.

The nature of the drive toward forming and maintaining intense attachments with other human beings has been examined in the light of case material from the play therapy sessions of a ten-year-old boy. The primary question addressed concerns the relationship of the attachment drive to other drive systems. Freudian theory, object relations theory, and attachment theory present competing paradigms for understanding the relationship between the drives. The Freudian paradigm sees human attachment as derivative from other drives, especially the sexual drive. In developing his attachment theory, Bowlby broke from the classical Freudian view. He postulated attachment as a primary and autonomous drive. Object relations theory, by contrast, sees sexuality as one manifestation of a more fundamental drive that is intrinsically relationship seeking. Each of these traditions has contributed to our understanding of human reality. A careful examination of the clinical material, however, strongly suggests that a drive toward relationship is intrinsic to libidinal energy. It is therefore concluded that the understanding of the relationship between the drives based on object relations theory provides us with the most adequate framework within which to understand the clinical material.

Parallel process in the supervision of child psychotherapy.

Parallel process is a phenomenon in which therapists unconsciously replicate the problems and dynamics of their clients during supervision. It has the unconscious aim of provoking the supervisor to demonstrate how to handle a perplexing situation. Recognizing and resolving parallel process when it occurs is an important supervisory skill. This paper focuses on the unique characteristics of parallel process in child psychotherapy. It reviews various types and manifestations, discusses several case examples, and outlines strategies for intervention.

Substance abuse in adolescent mothers: strategies for diagnosis, treatment and prevention.

Adolescent drug addiction and alcohol abuse are on the rise in this country. Teenagers of all races, socioeconomic groups and both genders have become avid experimenters with a full spectrum of substances, including alcohol, marijuana, stimulants, cocaine and hallucinogens. A diagnosis of addiction requires familiarity with the normative trends of adolescent behavior, as well as deviations from these trends. Moreover, an adolescent mother with a drug addiction problem confronts the additional burden of fostering adaptive developmental patterns in her infant. Treatment techniques such as previewing, which empowers through the representation and enactment of future outcomes, have helped addicted teenage mothers relinquish drug use and adopt more mature caregiving behaviors.